As Medicaid programs continue to grow in size, cost, and complexity, program integrity can no longer function as a standalone role—it must be built into the fabric of how programs operate daily.
Across the country, Medicaid leaders are navigating a convergence of pressures: rapid expansion of home- and community-based services (HCBS), increased regulatory scrutiny, and rising expectations to prevent fraud, waste, and abuse while preserving access and flexibility. For payers and state agencies alike, this raises a critical question: is the traditional, siloed approach to program integrity still sufficient? Increasingly, the answer is no.
A Familiar Assumption—and What Changes It
Self-directed care programs are sometimes perceived as carrying an inherently higher risk of fraud. Without visibility into how these programs function day to day, it’s easy to assume there are gaps in oversight. But a closer look often tells a different story.
In well-designed self-direction models, program integrity is not concentrated in a single team. Instead, it is reinforced across multiple touchpoints—eligibility checks, care planning, service authorization, time tracking, and payment processes. Information flows between stakeholders in near real time, creating multiple opportunities to identify and address issues early.
In this environment, fiscal management services (FMS) providers play a critical role—not as enforcers, but as connectors. They help translate program rules into operational processes and ensure consistency across participants, caregivers, and state partners. Electronic visit verification (EVV) enables the Medicaid recipient to validate that services were provided. Additional analytics support this approach by surfacing patterns, flagging anomalies such as overlapping shifts or excessive hours, and enabling earlier intervention through education and correction rather than retrospective enforcement.
The takeaway is that program integrity works best when it is shared, embedded, and continuous—not isolated within a single function.
Why Silos Fall Short
When integrity functions are siloed, eligibility in one place, service delivery in another, and oversight somewhere else, problems don’t always surface immediately. More often, they develop quietly and are discovered too late.
Consider eligibility as an example. In a siloed model, eligibility may be verified at enrollment but not consistently revalidated as circumstances change. If a participant’s status shifts due to hospitalization, coverage changes, or other factors, services and payments may continue based on outdated information. By the time the issue is identified, often during a retrospective audit, it requires a resource-intensive process of recoupment, reconciliation, and administrative follow-up.
In many cases, participants and caregivers acted in good faith, yet still experienced disruption. The issue is not individual failure, but a system design problem. Integrated models address this by bringing eligibility, authorization, service delivery, and payment into closer alignment, allowing discrepancies to be identified and resolved in real or near-real time.
Why This Matters Now
The stakes for getting program integrity right have never been higher. Self-directed care is expanding rapidly, serving more participants and caregivers across increasingly complex delivery environments. At the same time, states must balance oversight with access to ensure accountability without undermining the flexibility that makes these programs effective.
No single entity can monitor every aspect of a program in isolation, and a siloed model cannot keep pace with the scale and speed of today’s Medicaid landscape. A team-based approach distributes responsibility across the system and moves integrity upstream by embedding checks into everyday processes rather than relying solely on after-the-fact audits.
This shift enables earlier detection, faster resolution, and more efficient use of resources, all while maintaining a better experience for participants and caregivers.
A Stronger Model for the Future
For Medicaid leaders, the opportunity is clear: design programs where integrity is not an afterthought, but a core operating principle embedded across systems and stakeholders.
When program integrity is integrated in this way, issues are identified earlier, when they are easier and less costly to resolve. Accountability is shared rather than concentrated, administrative burden is reduced, and participants and caregivers experience fewer disruptions. Ultimately, this approach strengthens both oversight and care delivery.
In self-directed care, program integrity works best the same way care does—collaboratively, continuously, and as a shared responsibility. In today’s environment, integrity isn’t owned by one team; it is sustained by the entire system working together.
Explore how PPL is helping states embed program integrity across every step of care delivery - and how a more integrated approach can strengthen accountability across Medicaid.